Renowned expert Professor Joyce Wahr discusses why it’s so important to celebrate anaesthesia’s leadership in medication safety.
WFSA: What is medication safety and why is it relevant to World Anaesthesia Day?
Joyce: If I had to sum it up in a sentence it would be – delivering the right medicine to the right patient at the right dose and the right time, and using the right approach… so all the rights. Medication safety is making sure your plan is precise. An ‘error’ is a failure to carry out the plan as intended – or it’s a deficient plan to begin with.
This is so important for World Anaesthesia Day, as we have such a disparity in the safeguards in high-income versus medium and low-income countries. Unique challenges are faced in medium and low-income countries. Like falsified medications. In high-income settings, we don’t think when we pick up that propofol that it might be adulterated or falsified in some way. WAD2022 provides a fantastic opportunity for the community to share solutions and practices with each other.
WFSA: What’s the connection between medication safety and patient safety?
Joyce: For anaesthesia, they tend to be one and the same. The whole medication process is at the core of what we do. Yes, we put in central lines, we do monitoring, we may be in the critical care unit and all these other aspects. But when we think about ourselves as anaesthesia providers – we achieve our goal with medications.
WFSA: Analysis shows that one in 20 admissions to hospital experience a medication error. Why are so many mistakes made?
Joyce: It’s an incredibly complex enterprise- the circumstances are changing underneath you when trying to achieve an outcome. So, you may have a perfect plan for the patient as you begin the anaesthetic. And then in surgery, the patient’s condition is changing – you’ve got to adapt your plan. If you think it’s the wrong condition, you’ll have the wrong response, and grab the wrong medication. Throw in time pressure, a complex environment, complex teamwork with multiple people, and poor communication skills, and these errors do happen. On top of that, there isn’t leeway to recover from some of those errors.
WFSA: Why is medication safety such a big topic in anaesthesia specifically?
Joyce: Most of our medication errors are almost inconsequential but the medications we use can be lethal at the wrong dosages and ultimately have absolutely devastating consequences. In many locations, ampoules are nearly identical – they have the same colour printing and are exceedingly difficult to read. In high-income countries, we have nine different drugs on average. Antibiotics, induction agents, lidocaine, paralytic agents, narcotics and sedatives to name a few. So, there are just so many opportunities for error.
Anaesthesiologists are unique in that we’re the sole individual that prescribes, dispenses, prepares, administers and documents. Compare this to pharmaceutical conditions, where pharmacists do this quietly – often with two people – and double checking the file, the dilution, the formulation. We can’t do that in the intensity of the operating room.
WFSA: what expertise do anaesthesiologists bring to medication safety, when compared with other members of the surgical team?
Joyce: If you don’t enjoy pharmacology, you probably don’t choose to go into anaesthesia. It’s our primary job – our goal lies in giving the right medications to achieve the correct level of anaesthesia. And I think we do recognise that our medications are potentially lethal. Anything can happen really fast, at any time. We’ve probably all made a syringe swap at some point that frightened us.
WFSA: WAD2022 MedSafe campaign is looking to share universal medication safety steps that anaesthesia professionals take, that can apply anywhere globally. What are yours?
Joyce: This is amazing – but I’m not sure there are any universal truths. There’s huge variability. At the safest end, you have a prefilled syringe that has been made in a factory with intense scrutiny. That would eliminate vial swaps. And if barcode scanning is added at the time of administration, syringe swap risk is significantly reduced. And labelling syringes … but even colour-coded labels aren’t universal. Many providers can’t afford coloured labels and some resort to tying ribbons of the right colour around syringes. But even that might not be universal.
Universal standardisation is a good goal to aim for so, at every anaesthetising location, the carts look the same. Everybody places the syringes on top in the same order, and the medication drawers are standardised. Pharmacy could control the entire path of medication ordering, receiving the medication and putting them into the anaesthesia carts – that sort of thing – and preparing the high-risk medications.
WFSA: What are some soft skills that can improve medication practises?
Joyce: good teamwork in the operating room – not just with the surgeon but also with our circulating nurses. One of the common errors that we see is, say we’ve given a regional block with bupivacaine, and then the surgeon puts in a block – but we haven’t communicated with each other – now we have local anaesthesia toxicity. So these sorts of non-technical skills are so important.
A key communication tool is the brief before surgery and people do the brief very differently. Questions like ‘what surgery are we doing?’ ‘Do we have the right tools available?’ ‘What are the potential risks that we face?’ are so important for avoiding communication errors. That brief needs to be done and should be adapted to local conditions, though the core content should still be the same.
WFSA: What easily implemented medication safety tip or tactic do you most use?
Joyce: STAR. When I go to give a medication and I pick up the syringe, I have that STAR second. As soon as I pick it up, I Stop, Think, Act and Reflect. Afterwards, I reflect on whether it achieved the goal I wanted. You may have done the same procedure multiple times, but you only glance at the syringe once each time.
WFSA: The WHO has set a target of 50% reduction in the number of incidents of medication harm. Do you see this as achievable? What do you think needs to happen to make this happen?
Joyce: I think that goals are really important. It is incredibly difficult to know how often we even have medication harm in the operating room. I go back to James Reason’s safety paradoxes. One of the paradoxes is – we measure safety by counting the times when it’s absent. It becomes a big deal then, and so increases pressure on people to hide the event.
Personally, I’d prefer to see us set targets around improving safety processes. Errors typically occur due to a vulnerability in the local system. Having a particular group of pharmacists, anaesthesiologists and intensive units who look at our medication errors – who understand them, analyse the root causes and identify and correct them – would be useful. And encouraging the reporting of errors – even near misses – in the local reporting system. That would point to system vulnerabilities because, if the provider wasn’t more alert, it may have progressed into a harmful incident.
Professor Joyce Wahr is a Professor of Anesthesiology and Vice-Chair for Quality and Safety in the Department of Anesthesiology at the University of Minnesota. Alongside an extensive list of journal articles on medication safety she also co-authored with Dr Alan Merry, Medication Safety during Anesthesia and the Perioperative Period.
Prof Wahr was talking to WFSA’s Sophie Harris and Francis Peel. Title photograph by Maria Fernanda Gauer Pilatti
